By Charles Bankhead, Staff Writer, MedPage Today
Published: October 09, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner
HIV mortality has decreased significantly across racial and ethnic groups and in men and women but remains much higher in nonwhite than in white individuals, an analysis of vital statistics showed.
In absolute terms, the largest decreases occurred among black men with the most education (117.89 per 100,000 population during 1993 to 1995, and 15.35/100,000 in 2005 to 2007) and Hispanic men with the least education (61.60 versus 9.01/100,000), according to Edgar P. Simard, PhD, of the American Cancer Society in Atlanta, and co-authors.
Although mortality declined in both sexes and across all education levels, rates remained substantially higher in minority groups, owing to higher baseline rates, they reported online in Archives of Internal Medicine.
"There were strong declines for all groups except for non-Hispanic black women of low SES (socioeconomic status)," the authors wrote in conclusion. "Relative declines were generally greater for those with higher educational attainment and for non-Hispanic whites, and these trends resulted in widening gaps between these groups."
"The black-to-white mortality disparities were generally similar across educational levels in both periods ... , highlighting racial disparities in HIV prevalence, treatment, and prevention within each level of education, which may be due to a combination of societal and environmental factors," they added.
Total HIV mortality has declined substantially since the mid-1990s. Overall declines can obscure subgroups that have benefited more or less from earlier diagnosis and highly active antiretroviral therapy (HAART). Simard and colleagues sought to identify such subgroups by examining trends over time in HIV mortality by sex, race/ethnicity, and education level.
The authors searched the National Vital Statistics System for HIV-related deaths among men and women ages 25 to 64 in 26 states, covering the years 1993 to 2007, inclusive.
Investigators compared mortality during two periods: 1993 to 1995 (pre-HAART) and 2005 to 2007 (HAART era). The primary outcomes were age-standardized HIV mortality, mortality differences, and rate ratios by education and between the least- and most-educated individuals (≤12 versus ≥16 years).
The search of the database identified 91,307 HIV deaths during 1993 to 2007 (74,445 men and 16,862 women). White men accounted for 35,149 deaths, black men for 34,783, and Hispanic men for 4,513. Corresponding numbers for women were 4,147, 11,663, and 1,052, respectively.
Comparison of the pre-HAART and HAART eras showed little variation in death rates by education among white men (25.77 to 26.42/100,000 for least to most education) in the pre-HAART period. By 2005 to 2007, rates had declined to 5.04, 2.82, and 1.79/per 100,000 for white men with ≤12 years, 13 to 15 years, and ≥16 years of education, respectively.
Black men with the least education had the highest mortality in both periods: 122.02/100,000 during 1993 to 1995 and 52.71/100,000 in 2005 to 2007.
Among Hispanic men, those with the least education had an HIV mortality of 58.67/100,000 during 1993 to 1995, declining to 9.01/100,000 during 2005 to 2007. Hispanic men with the most education had HIV death rates of 49.84 and 3.13/100,000 for the early and later periods of years included in the study.
For both the pre-HAART and HAART eras, women of all races and education levels had lower HIV mortality compared with men. Nonetheless, HIV mortality declined across the board: 1.97 to 0.80/100,000 in white women; 22.50 to 16.97/100,000 in black women; and 12.24 to 2.32/100,000 in Hispanic women.
Despite declines in HIV mortality across all ethnic groups, disparities increased by level of education in two groups: most- and least-educated white men and black men.
During 1993 to 1995, the mortality disparity by education in white men was <1/100,000 but increased to >3/100,000 by 2005 to 2007. Among black men, the education-related disparity increased from ~4/100,000 during 1993 to 1995 to >37/100,000 during 2005 to 2007.
"HIV death rates remained markedly high among non-Hispanic black men of all SES levels and were unchanged for non-Hispanic black women in the lowest SES strata," the authors wrote in conclusion.
"These findings suggest the need for focused interventions and resources to facilitate the identification of high-risk individuals, as well as entry and retention into care for these most vulnerable groups affected by the HIV epidemic in the U.S."
The study was supported by the American Cancer Society.
The authors had no disclosures.
Primary source: Archives of Internal Medicine
Simard EP, et al "The influence of sex, race/ethnicity, and educational attainment on human immunodeficiency virus death rates among adults, 1993-2007" Arch Intern Med 2012; DOI: 10.1001/archinternmed.2012.4508.